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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Menorrhagia is menstrual blood loss which interferes with a woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. Any intervention should aim to improve her quality of life. Research studies usually take menorrhagia to be a monthly menstrual blood loss in excess of 80 ml.

What is normal?

The average menstrual cycle has a blood loss for seven days of a cycle of between 21 and 35 days. The usual shorthand for this is:

K = 7/21-35 in which K represents menstrual cycle, 7 is the duration of bleeding and 21-35 represents the length of the cycle.

Menstrual loss is heaviest for the first few days and becomes much lighter, tailing off towards the end.

Other definitions include:

Metrorrhagia - flow at irregular intervals.

Menometrorrhagia - frequent and excessive flow.

Polymenorrhoea - bleeding at intervals of less than 21 days.

Dysfunctional uterine bleeding (DUB) - abnormal uterine bleeding without any obvious structural or systemic pathology.[1]It usually presents as menorrhagia. The diagnosis of DUB can only be made once all other causes for abnormal, or heavy, uterine bleeding have been excluded.

Dysmenorrhoea - pain with menstruation.

The average menstrual blood loss is about 30-40 ml.[2] Many women who complain of heavy menstruation do not in fact have blood loss in excess of 80 ml. Menorrhagia is very subjective; a more practical definition may be that it is menstrual loss that is greater than the woman feels she can reasonably manage. The National Institute for Health and Care Excellence (NICE) defines heavy menstrual loss as excessive blood loss that interferes with a woman's physical, social, emotional and/or quality of life.[3]

Menorrhagia is related to increased limitations in physical activities and limitations in social and leisure activities.[4]

Epidemiology

The perception of what constitutes "heavy" menstrual bleeding is subjective. The prevalence of menorrhagia ranges from 9-14% in studies that assess menstrual blood loss objectively by measuring it, but is much higher (20-52%) in studies which are based on subjective assessment.[5]

DUB is more common around the menarche and perimenopause.

1 in 20 women aged 30-49 years consult their GP each year for heavy periods and menstrual disorders.[6]

Menstrual disorders are the second most common gynaecological condition to be referred to hospital, accounting for around 12% of all gynaecological referrals.[2]

40-60% of those who complain of excessive bleeding have no pathology and this is called DUB.

20% of cases are associated with anovulatory cycles and these are most common at the extremes of reproductive life.

Local causes include:

Fibroids.

Endometrial polyps.

Endometriosis.

Adenomyosis.

Endometritis.

Pelvic inflammatory disease (PID).

Endometrial hyperplasia or carcinoma. Endometrial carcinoma presents in women aged over 50 years in the majority of cases and classically with postmenopausal bleeding; however, some cases present with abnormalities of the menstrual cycle. 90% present with abnormal uterine bleeding in some form.[7]

History

Note the total duration of bleeding and how much of that time it is heavy. Over 90% of menstrual loss occurs in the first three days and there is no correlation with the duration of loss and the total volume. Pictorial blood loss assessment charts may be useful.

Note the length of the cycle, ie the duration from the start of one period to the start of the next.

If the patient has to wear tampons and towels simultaneously, flow is heavy.

The passage of clots represents heavy flow. Clots may be painful as they pass through the cervix.

Ultrasound (ideally transvaginal) is the first-line diagnostic tool for identifying structural abnormalities - eg, fibroids. An endometrial thickness of <12 mm is normal in pre-menopausal women. In addition, hysteroscopy can be used to assess the endometrial cavity.

Any woman referred to specialist care should be given information before her outpatient appointment. NICE has information for patients - available from the link below.

Not everyone needs referral to secondary care.[3]If history and FBC are reassuring, medical treatment should be considered, if required. Medical treatment can be instituted in primary care. Patients are referred to exclude sinister pathology and when treatment in primary care has failed.

The main aims of treatment are to improve symptoms and also quality of life. Women should be advised on advantages and disadvantages of treatments and should also receive written information.

Pharmacological

When a first pharmaceutical treatment has proved ineffective then a second pharmaceutical treatment should be considered rather than immediate referral to surgery. If there is iron deficiency it should be corrected with oral iron.

First-line treatmentThis is the LNG-IUS - Mirena®. This is long-term treatment and should be left in situ for at least 12 months.[3]

Studies show that women with menorrhagia reported more improvement in bleeding and quality of life with the LNG-IUS than with other treatments available in primary care. In addition, they were more likely to continue with this treatment.[8]

However, the rate of discontinuation of Mirena® treatment has been shown to be relatively high - 16% at 12 months and 28% by 2 years.[6]

The IUS is more effective than oral treatment, results in more reduction in bleeding and more improvement in quality of life and is more acceptable long-term. However, there are more minor adverse effects with the IUS than with oral treatment.

The IUS is similar in outcome to ablation but is more cost-effective. Again there are more minor adverse effects reported. Overall satisfaction rates are similar.

In comparison to hysterectomy, the IUS is less effective but more cost-effective, and is not associated with the complications and risks attached to major surgery.

Mefenamic acid works by inhibiting prostaglandin synthesis. It reduces menstrual loss by around 25% in three quarters of women and is better tolerated than tranexamic acid. Naproxen and ibuprofen may also be used and no difference has been demonstrated between the NSAIDs.[9]They are less effective than tranexamic acid.

Tranexamic acid is a plasminogen-activator inhibitor. It inhibits the dissolution of thrombosis that leads to menstrual flow. It can reduce flow by up to 50%.[10] It is most effective at reducing menstrual loss associated with IUCDs, fibroids and bleeding diathesis. Side-effects include nausea, vomiting and diarrhoea. If there is disturbance in colour vision then it should be discontinued.

The COC suppresses production of gonadotrophins and is thought to reduce menstrual blood loss by up to 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, improve premenstrual symptoms, reduce the risk of PID and protect the ovaries and endometrium against cancer. A Cochrane review found a paucity of evidence surrounding the efficacy of the COC for this indication.[11]

Third-line treatmentThis is with progestogens, either norethisterone 5 mg tds from day 5 to 26, or injected long-acting progestogens such as medroxyprogesterone acetate (Depo-Provera®) every 12 weeks. A Cochrane review found this to be less effective than other medical options and less acceptable to women.[12] This regimen of progestogen may have a role in the short-term treatment of menorrhagia.

There are very limited data regarding the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular menstrual bleeding associated with anovulation. There is still no consensus about which regimens are the most effective.[13]

In secondary care 3-4 months of a gonadotrophin-releasing hormone (GnRH) analogue may be offered before hysterectomy or myomectomy, where the uterus is enlarged or distorted by fibroids. It is also a reasonable choice of therapy if other methods are contra-indicated - but 'add-back' hormone therapy will be needed if continued for >6 months. GnRH analogues have also been used prior to endometrial ablative surgery.[14]GnRH analogues should not be initiated in primary care.

In the acute situation, a bleeding episode may be so disabling for the woman that treatment with high-dose norethisterone (30 mg daily) needs to be used (off-label). This is continued until bleeding is controlled, but is then tailed off.

Surgical options

Surgery, and in particular hysterectomy, improves heavy menstrual bleeding more effectively than medical options.[15]However because of the reversibility of medical treatment and the added risks and complications of surgery, surgical treatment is not usually considered first-line.

The choice of treatment will depend on both the uterine size and the woman's desire to retain her uterus:

Endometrial ablationThis is the recommended first-line treatment if the uterus is <10 weeks of gestation on palpation.[3]It involves removing the full thickness of the endometrium together with the superficial myometrium and the basal glands thought to be the focus of endometrial growth. It retains the uterus.

Endometrial ablation is contra-indicated in women with large fibroids or suspected malignancy and in those who have not completed their family.

There are various types of endometrial ablation:

Impedance-controlled bipolar radiofrequency ablation: a bipolar radiofrequency electrode is placed through the cervix and radiofrequency energy is delivered to the uterus.

Balloon thermal ablation: a balloon is inserted through the cervix to the endometrial cavity, inflated with a pressurised solution and then heated to destroy the endometrium.

Microwave ablation: a microwave probe is inserted into the uterine cavity to heat the endometrium and moved side-to-side to destroy it.

Free fluid thermal ablation: heated saline is used to destroy the endometrium.

Rollerball ablation: a current is passed through a rollerball electrode which is moved around the endometrium.

Transcervical resection of the endometrium: small fibroids are removed using a cutting loop.

Unwanted outcomes of ablation include vaginal discharge; increased period pain (even if there is no further bleeding); the need for additional surgery; infection; perforation (very rare). NB: contraception after endometrial ablation is still advised even though fertility is usually not retained.

Cochrane reviews have found endometrial ablation to be an effective alternative to hysterectomy, with high satisfaction rates.[16]

Uterine artery embolisation or hysteroscopic myomectomyIf the uterus is >10 weeks in size and the woman wishes to retain her uterus, treatment options are uterine artery embolisation or hysteroscopic myomectomy.

HysterectomyIf the patient does not wish to retain the uterus, then treatment is with hysterectomy - first consider vaginal, then abdominal with conservation of ovaries, if appropriate. Healthy ovaries should not be removed.

Hysterectomy is not first-line surgical management for DUB. Only consider when:

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.